University Hospital in Mirebalais: a state of the art 300-bed teaching hospital in rural Haiti.

The right to health movement is a political struggle for moving resources down the gradient of inequality in ways that can strengthen public sector universal health care delivery systems that meet the needs of citizens. Current policy, governance, and financing structures are insufficient for this aim. But, how should it be governed? What changes are needed at the WHO? What types of investments should be prioritized?

A recent post to the Health Affairs blog, written by heavy hitters such as the founding executive director of the Global Fund to Fight AIDS, TB, and Malaria, Sir Richard Feachem amongst others, highlights one of these debates: at what level of the health system should investments primarily be made?

The authors argue that we’ve focused heavily (perhaps too heavily) on funding narrowly constructed, vertical disease-specific programs:

“For the past four decades, donors have mainly funded disease-specific programs and global discourse has focused on the need for better primary care. In combination, these have contributed to remarkable progress in meeting many of the MDG health targets, especially those relating to child mortality, HIV/AIDS, and malaria.

Targeted programs and a primary care focus have been less successful, however, in achieving some of the other MDGs — most notably in the areas of maternal and neonatal mortality. While many papers and conferences have been devoted to the topic of “health systems strengthening,” funding priorities and programmatic approaches have remained narrowly targeted on diseases, or on a single platform of delivery: primary care.”

They argue that to meet the broader and more ambitious targets in the Sustainable Development Goals (specifically, to “ensure healthy lives and promote well-being for all at all ages.”) we need to have a renewed focus on hospitals and similar secondary/tertiary-level facilities as a crucial component of integrated primary care.

“Within the continuum of care services, insufficient attention has been paid to access to high quality hospital services. In both low- and middle-income countries, hospital quality and safety has lagged; in 2009, 15.5 million disability-adjusted life years (DALYs) were lost due to in-hospital adverse events. Despite domestic resources in most countries being disproportionately allocated to hospital care,hospitals in many low-income countries are inaccessible or are in a dismal state. Even with comparatively large expenditures on hospitals versus other modes of delivery, total domestic health expenditures are often too low to provide a good quality health system. These conditions are exacerbated by ineffective spending and lack of management accountability.

As a consequence, public hospitals in these countries are often dilapidated, lacking a reliable water supply, sanitation, and electricity. Drugs and other supplies may be unavailable, equipment is frequently broken, and basic infection control is absent. This makes it difficult, if not impossible, for limited medical personnel to ensure good health outcomes.

We argue that for personal health services, which are the focus of this perspective, it is now timely to rebalance the global health discourse and focus on the integration of primary care with essential hospital services. A strong health system needs both.”

They point to narrowly conceived cost-effectiveness analysis as a reason for insufficient investments in the capital intensive process of building and maintaining adequate tertiary-level facilities. They liken it to the investments in education made across Africa which have avoided higher education and specialty training, deemed too expensive for poor people.

“The SDGs call for health for all individuals, present and future. All platforms of care delivery are necessary for health system success, and none are individually sufficient. Building health systems with a long view—to sustainably preserve and attain health—requires an integrated approach where one platform supports, rather than competes with, another. Putting hospitals on the agenda alongside other platforms of care is not the whole solution, but it is a necessary part of the solution, if we are to have any likelihood of achieving the SDGs.”